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Vision Screening Parent Questionnaire for Children Ages Birth through Five Years
Child’s Name: Child’s DOB: ____________________
regi NaCa ver me: Date: __________________________
Community Center Board: District: ________________________
Contact Person: Email: __________________________
This tool has been developed to address cursory vision screening practices for children ages birth through five years of age. It should be completed by a caregiver who knows the child best. The information will determine if there are vision concerns that warrant further evaluation when in-person screening or assessment activities can resume.
It is important to have information about possible vision concerns that may occur with other family members, as well as general medical information about your child.
General History: High Risk Populations for Visual Problems
No
No Has your child been diagnosed with a syndrome (e.g. Down syndrome, CHARGE Yes syndrome, etc.?) Has your child been diagnosed as having cerebral palsy? Yes
Yes No Does your child have any difficulties with his or her hearing?
Yes No Does your child have any neurological disorders (e.g. seizures, hydrocephaly)?
No Has your child experienced any form of brain injury / head trauma? (in utero Yes stroke, brain hemorrhage, lack of oxygen, accidental or non-accidental trauma)
Yes No Has your child had meningitis or encephalitis?
Yes No Was your child exposed to alcohol or drugs before birth?
Yes No Was your child born prematurely?
No Yes Did your baby weigh fewer than three pounds at birth? No Yes Was your child exposed to any prenatal infections (e.g. toxoplasmosis, CMV)?
Yes No Is there a family history of eye crossing, color vision problems, and/or needing prescription glasses?
No Is there a family history of early onset vision loss (e.g., cataracts, albinism, etc.?) Yes
1
Rehan Castro 12/7/18
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R.Castro (1)
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The ABCs of Early Vision Problems
Background Information: We can learn a lot about the health and well-being of a young child’s vision by paying attention to the appearance of his or her eyes, visual behaviors, and complaints. Thank you for your assistance with this information to determine if there is a concern about your child’s vision.
Appearance of the Eyes / Eyelids: Please take a few moments to observe the child eyes and eyelids.Answer yes or no the statements below. If you are unsure, leave the question blank for consultation from Part C or school district Child Find professionals with appropriate expertise.
One eye looks different than the other eye. For example, one eye is significantly smaller in appearance or one eye is higher on the face than the other eye.
Yes No
One or both eyes turn inward or outward. This can happen all of the time or only some of the time.
Yes No
There is a difference in the black color, size or shape of the pupils in one or both eyes. The pupil is the dark black center of each eye.
Yes No
There is a difference in the size and shape of the iris in one or both eyes. The iris is the colored part of each eye.
Yes No
One or both eyes appear white or cloudy. Yes No
Eyes are in involuntary, rapid (dancing/ jiggling up and down or side to side) motion.
Yes No
Eye(s) are red and/or excessively mattered (beyond the usual sleep matter when the child first awakens or due to allergies).
Yes No
Eyelids are red, swollen, and/or are encrusted. Yes No
An eyelid(s) is drooping or appears lower than the other. Yes No
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R.Castro (1)
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Behavior: Please report your observations of how your child uses vision in daily tasks. Answer yes or nothe statements below. If you are unsure, leave the question blank for consultation from Part C or school district Child Find professionals with appropriate expertise.
Does your child …. Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Consistently NOT make eye contact with familiar people (after two months of age).
Cover or close an eye when looking at someone or something within close range (two feet or closer). Frown or squint an eye when looking at something far away (two feet or further).
Tilt / turn head to the side, lift /lower chin, and/or thrust head forward or backward when looking at something at near or far range. Circle which behavior occurs. Close eyes or turns face away when listening to others talk.
mile in response to another person’s smile.
Hold an object very close to his or her eyes when looking at it.
Stare at lights sources (overhead lights or windows) for a long period of time.
Prefer certain colors; chooses items with these colors over items with other colors. (e.g., seems to look more intently at objects that are red.)
Recognize familiar people only after they speak.
Notice people, pets, or objects only when they are moving
Seem to have inconsistent visual abilities (e.g. seems to change from morning to night or from day to day or between activities).
Miss objects he or she is simultaneously looking at and reaching for (e.g. require multiple attempts to get the item). Look away when reaching toward a nearby object.
Stumble frequently over objects that are in his or her path or bump into walls.
Have difficulties detecting a change in floor surface, such as from tile to carpet. Hesitate or miss detecting step or a curb.
Yes No
Have trouble seeing small objects, such as a small piece of cereal left on tray / table. Yes No
Lose interest quickly in games, projects or activities that require using his or her eyes for an extended period of time.
Yes No
Avoid looking at books, drawing, playing games or doing other projects that require focusing up close.
Yes No
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R.Castro (1)
Complaints: A young child will not usually “complain” about visual difficulties, but may show throughbehavior that something is not right with his or her vision. Answer yes or no the statements below. If you are unsure, leave the question blank for consultation from Part C or school district Child Find professionals with appropriate expertise.
Does your child …. Appear to be overly sensitive to bright indoor lights or the sunlight. Squint excessively, put a hand over his eyes, or put his head down to avoid the light.
Yes No
Seem to have burning or itchy eyes, rub his or her eyes, rapidly blink, and/or have teary eyes not due to allergies.
Yes No
Rub his or her eyes or blink rapidly after looking at something (when he or she is not tired).
Yes No
Appear to only see an object when it’s separated (isolated?) from other items (e.g. cannot find a specific toy when it’s among other objects).
Yes No
Do you have any concerns about your child’s vision that were not addressed in the previous questions? If yes, please describe.
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Has your child ever been seen by an eye doctor (optometrist or ophthalmologist?) Yes No
If yes, what were the results of the exam? _____________________________________________
____________________________________________________________________________________________________________
No
No
Were glasses or another treatment prescribed? Yes
If yes, does your child wear the glasses, as prescribed? Yes
If not, what is the reason the child is not wearing his or her glasses:
______________________________________________________________________________
Next Steps: Thank you for providing information about your child’s vision. This information will be reviewed with your Part C or Child Find contact person to determine appropriate next steps.
References:
Colorado Department of Education (2005). Visual Screening Guidelines: Children Birth through Five Years, Colorado Department of Education.
Teach CVI (2020). Screening List for Children with a Suspicions of a Cerebral Visual Impairment CVI) / Screen List CVI 1 retrieved from https://f9d3e3e2-4dd0-4434-a4bb-27a978ad3a27.filesusr.com/ugd/eca85c_7ca670026a8d4f388c5d63828ec0610d.pdf
Topor, I. (2004). Approximate functional visual acuity for different sizes of objects and distances. Chapel Hill,
NC: Early Intervention Training Center for Infants and Toddlers with Visual Impairments, FPG Child Development Institute, UNC-CH.
4
None
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R.Castro (1)
Vision Screening Parent Questionnaire for Children Ages Birth through Five Years
Child’s Name: Child’s DOB: ____________________
regi NaCa ver me: Date: __________________________
Community Center Board: District: ________________________
Contact Person: Email: __________________________
This tool has been developed to address cursory vision screening practices for children ages birth through five years of age. It should be completed by a caregiver who knows the child best. The information will determine if there are vision concerns that warrant further evaluation when in-person screening or assessment activities can resume.
It is important to have information about possible vision concerns that may occur with other family members, as well as general medical information about your child.
General History: High Risk Populations for Visual Problems
No
No Has your child been diagnosed with a syndrome (e.g. Down syndrome, CHARGE Yes syndrome, etc.?) Has your child been diagnosed as having cerebral palsy? Yes
Yes No Does your child have any difficulties with his or her hearing?
Yes No Does your child have any neurological disorders (e.g. seizures, hydrocephaly)?
No Has your child experienced any form of brain injury / head trauma? (in utero Yes stroke, brain hemorrhage, lack of oxygen, accidental or non-accidental trauma)
Yes No Has your child had meningitis or encephalitis?
Yes No Was your child exposed to alcohol or drugs before birth?
Yes No Was your child born prematurely?
No Yes Did your baby weigh fewer than three pounds at birth? No Yes Was your child exposed to any prenatal infections (e.g. toxoplasmosis, CMV)?
Yes No Is there a family history of eye crossing, color vision problems, and/or needing prescription glasses?
No Is there a family history of early onset vision loss (e.g., cataracts, albinism, etc.?) Yes
1
Juniper Hilfman 6/29/19
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J.Hilfman (2)
2
The ABCs of Early Vision Problems
Background Information: We can learn a lot about the health and well-being of a young child’s vision by paying attention to the appearance of his or her eyes, visual behaviors, and complaints. Thank you for your assistance with this information to determine if there is a concern about your child’s vision.
Appearance of the Eyes / Eyelids: Please take a few moments to observe the child eyes and eyelids.Answer yes or no the statements below. If you are unsure, leave the question blank for consultation from Part C or school district Child Find professionals with appropriate expertise.
One eye looks different than the other eye. For example, one eye is significantly smaller in appearance or one eye is higher on the face than the other eye.
Yes No
One or both eyes turn inward or outward. This can happen all of the time or only some of the time.
Yes No
There is a difference in the black color, size or shape of the pupils in one or both eyes. The pupil is the dark black center of each eye.
Yes No
There is a difference in the size and shape of the iris in one or both eyes. The iris is the colored part of each eye.
Yes No
One or both eyes appear white or cloudy. Yes No
Eyes are in involuntary, rapid (dancing/ jiggling up and down or side to side) motion.
Yes No
Eye(s) are red and/or excessively mattered (beyond the usual sleep matter when the child first awakens or due to allergies).
Yes No
Eyelids are red, swollen, and/or are encrusted. Yes No
An eyelid(s) is drooping or appears lower than the other. Yes No
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J.Hilfman (2)
3
Behavior: Please report your observations of how your child uses vision in daily tasks. Answer yes or nothe statements below. If you are unsure, leave the question blank for consultation from Part C or school district Child Find professionals with appropriate expertise.
Does your child …. Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Consistently NOT make eye contact with familiar people (after two months of age).
Cover or close an eye when looking at someone or something within close range (two feet or closer). Frown or squint an eye when looking at something far away (two feet or further).
Tilt / turn head to the side, lift /lower chin, and/or thrust head forward or backward when looking at something at near or far range. Circle which behavior occurs. Close eyes or turns face away when listening to others talk.
mile in response to another person’s smile.
Hold an object very close to his or her eyes when looking at it.
Stare at lights sources (overhead lights or windows) for a long period of time.
Prefer certain colors; chooses items with these colors over items with other colors. (e.g., seems to look more intently at objects that are red.)
Recognize familiar people only after they speak.
Notice people, pets, or objects only when they are moving
Seem to have inconsistent visual abilities (e.g. seems to change from morning to night or from day to day or between activities).
Miss objects he or she is simultaneously looking at and reaching for (e.g. require multiple attempts to get the item). Look away when reaching toward a nearby object.
Stumble frequently over objects that are in his or her path or bump into walls.
Have difficulties detecting a change in floor surface, such as from tile to carpet. Hesitate or miss detecting step or a curb.
Yes No
Have trouble seeing small objects, such as a small piece of cereal left on tray / table. Yes No
Lose interest quickly in games, projects or activities that require using his or her eyes for an extended period of time.
Yes No
Avoid looking at books, drawing, playing games or doing other projects that require focusing up close.
Yes No
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J.Hilfman (2)
Complaints: A young child will not usually “complain” about visual difficulties, but may show throughbehavior that something is not right with his or her vision. Answer yes or no the statements below. If you are unsure, leave the question blank for consultation from Part C or school district Child Find professionals with appropriate expertise.
Does your child …. Appear to be overly sensitive to bright indoor lights or the sunlight. Squint excessively, put a hand over his eyes, or put his head down to avoid the light.
Yes No
Seem to have burning or itchy eyes, rub his or her eyes, rapidly blink, and/or have teary eyes not due to allergies.
Yes No
Rub his or her eyes or blink rapidly after looking at something (when he or she is not tired).
Yes No
Appear to only see an object when it’s separated (isolated?) from other items (e.g. cannot find a specific toy when it’s among other objects).
Yes No
Do you have any concerns about your child’s vision that were not addressed in the previous questions? If yes, please describe.
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Has your child ever been seen by an eye doctor (optometrist or ophthalmologist?) Yes No
If yes, what were the results of the exam? _____________________________________________
____________________________________________________________________________________________________________
No
No
Were glasses or another treatment prescribed? Yes
If yes, does your child wear the glasses, as prescribed? Yes
If not, what is the reason the child is not wearing his or her glasses:
______________________________________________________________________________
Next Steps: Thank you for providing information about your child’s vision. This information will be reviewed with your Part C or Child Find contact person to determine appropriate next steps.
References:
Colorado Department of Education (2005). Visual Screening Guidelines: Children Birth through Five Years, Colorado Department of Education.
Teach CVI (2020). Screening List for Children with a Suspicions of a Cerebral Visual Impairment CVI) / Screen List CVI 1 retrieved from https://f9d3e3e2-4dd0-4434-a4bb-27a978ad3a27.filesusr.com/ugd/eca85c_7ca670026a8d4f388c5d63828ec0610d.pdf
Topor, I. (2004). Approximate functional visual acuity for different sizes of objects and distances. Chapel Hill,
NC: Early Intervention Training Center for Infants and Toddlers with Visual Impairments, FPG Child Development Institute, UNC-CH.
4
None
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J.Hilfman (2)
Vision Screening Parent Questionnaire for Children Ages Birth through Five Years
Child’s Name: Child’s DOB: ____________________
regi NaCa ver me: Date: __________________________
Community Center Board: District: ________________________
Contact Person: Email: __________________________
This tool has been developed to address cursory vision screening practices for children ages birth through five years of age. It should be completed by a caregiver who knows the child best. The information will determine if there are vision concerns that warrant further evaluation when in-person screening or assessment activities can resume.
It is important to have information about possible vision concerns that may occur with other family members, as well as general medical information about your child.
General History: High Risk Populations for Visual Problems
No
No Has your child been diagnosed with a syndrome (e.g. Down syndrome, CHARGE Yes syndrome, etc.?) Has your child been diagnosed as having cerebral palsy? Yes
Yes No Does your child have any difficulties with his or her hearing?
Yes No Does your child have any neurological disorders (e.g. seizures, hydrocephaly)?
No Has your child experienced any form of brain injury / head trauma? (in utero Yes stroke, brain hemorrhage, lack of oxygen, accidental or non-accidental trauma)
Yes No Has your child had meningitis or encephalitis?
Yes No Was your child exposed to alcohol or drugs before birth?
Yes No Was your child born prematurely?
No Yes Did your baby weigh fewer than three pounds at birth? No Yes Was your child exposed to any prenatal infections (e.g. toxoplasmosis, CMV)?
Yes No Is there a family history of eye crossing, color vision problems, and/or needing prescription glasses?
No Is there a family history of early onset vision loss (e.g., cataracts, albinism, etc.?) Yes
1
Ezequiel Montes 6/28/19
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E.Montes (3)
2
The ABCs of Early Vision Problems
Background Information: We can learn a lot about the health and well-being of a young child’s vision by paying attention to the appearance of his or her eyes, visual behaviors, and complaints. Thank you for your assistance with this information to determine if there is a concern about your child’s vision.
Appearance of the Eyes / Eyelids: Please take a few moments to observe the child eyes and eyelids.Answer yes or no the statements below. If you are unsure, leave the question blank for consultation from Part C or school district Child Find professionals with appropriate expertise.
One eye looks different than the other eye. For example, one eye is significantly smaller in appearance or one eye is higher on the face than the other eye.
Yes No
One or both eyes turn inward or outward. This can happen all of the time or only some of the time.
Yes No
There is a difference in the black color, size or shape of the pupils in one or both eyes. The pupil is the dark black center of each eye.
Yes No
There is a difference in the size and shape of the iris in one or both eyes. The iris is the colored part of each eye.
Yes No
One or both eyes appear white or cloudy. Yes No
Eyes are in involuntary, rapid (dancing/ jiggling up and down or side to side) motion.
Yes No
Eye(s) are red and/or excessively mattered (beyond the usual sleep matter when the child first awakens or due to allergies).
Yes No
Eyelids are red, swollen, and/or are encrusted. Yes No
An eyelid(s) is drooping or appears lower than the other. Yes No
✔
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E.Montes (3)
3
Behavior: Please report your observations of how your child uses vision in daily tasks. Answer yes or nothe statements below. If you are unsure, leave the question blank for consultation from Part C or school district Child Find professionals with appropriate expertise.
Does your child …. Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Consistently NOT make eye contact with familiar people (after two months of age).
Cover or close an eye when looking at someone or something within close range (two feet or closer). Frown or squint an eye when looking at something far away (two feet or further).
Tilt / turn head to the side, lift /lower chin, and/or thrust head forward or backward when looking at something at near or far range. Circle which behavior occurs. Close eyes or turns face away when listening to others talk.
mile in response to another person’s smile.
Hold an object very close to his or her eyes when looking at it.
Stare at lights sources (overhead lights or windows) for a long period of time.
Prefer certain colors; chooses items with these colors over items with other colors. (e.g., seems to look more intently at objects that are red.)
Recognize familiar people only after they speak.
Notice people, pets, or objects only when they are moving
Seem to have inconsistent visual abilities (e.g. seems to change from morning to night or from day to day or between activities).
Miss objects he or she is simultaneously looking at and reaching for (e.g. require multiple attempts to get the item). Look away when reaching toward a nearby object.
Stumble frequently over objects that are in his or her path or bump into walls.
Have difficulties detecting a change in floor surface, such as from tile to carpet. Hesitate or miss detecting step or a curb.
Yes No
Have trouble seeing small objects, such as a small piece of cereal left on tray / table. Yes No
Lose interest quickly in games, projects or activities that require using his or her eyes for an extended period of time.
Yes No
Avoid looking at books, drawing, playing games or doing other projects that require focusing up close.
Yes No
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E.Montes (3)
Complaints: A young child will not usually “complain” about visual difficulties, but may show throughbehavior that something is not right with his or her vision. Answer yes or no the statements below. If you are unsure, leave the question blank for consultation from Part C or school district Child Find professionals with appropriate expertise.
Does your child …. Appear to be overly sensitive to bright indoor lights or the sunlight. Squint excessively, put a hand over his eyes, or put his head down to avoid the light.
Yes No
Seem to have burning or itchy eyes, rub his or her eyes, rapidly blink, and/or have teary eyes not due to allergies.
Yes No
Rub his or her eyes or blink rapidly after looking at something (when he or she is not tired).
Yes No
Appear to only see an object when it’s separated (isolated?) from other items (e.g. cannot find a specific toy when it’s among other objects).
Yes No
Do you have any concerns about your child’s vision that were not addressed in the previous questions? If yes, please describe.
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Has your child ever been seen by an eye doctor (optometrist or ophthalmologist?) Yes No
If yes, what were the results of the exam? _____________________________________________
____________________________________________________________________________________________________________
No
No
Were glasses or another treatment prescribed? Yes
If yes, does your child wear the glasses, as prescribed? Yes
If not, what is the reason the child is not wearing his or her glasses:
______________________________________________________________________________
Next Steps: Thank you for providing information about your child’s vision. This information will be reviewed with your Part C or Child Find contact person to determine appropriate next steps.
References:
Colorado Department of Education (2005). Visual Screening Guidelines: Children Birth through Five Years, Colorado Department of Education.
Teach CVI (2020). Screening List for Children with a Suspicions of a Cerebral Visual Impairment CVI) / Screen List CVI 1 retrieved from https://f9d3e3e2-4dd0-4434-a4bb-27a978ad3a27.filesusr.com/ugd/eca85c_7ca670026a8d4f388c5d63828ec0610d.pdf
Topor, I. (2004). Approximate functional visual acuity for different sizes of objects and distances. Chapel Hill,
NC: Early Intervention Training Center for Infants and Toddlers with Visual Impairments, FPG Child Development Institute, UNC-CH.
4
None
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E.Montes (3)
Vision Screening Parent Questionnaire for Children Ages Birth through Five Years
Child’s Name: Child’s DOB: ____________________
regi NaCa ver me: Date: __________________________
Community Center Board: District: ________________________
Contact Person: Email: __________________________
This tool has been developed to address cursory vision screening practices for children ages birth through five years of age. It should be completed by a caregiver who knows the child best. The information will determine if there are vision concerns that warrant further evaluation when in-person screening or assessment activities can resume.
It is important to have information about possible vision concerns that may occur with other family members, as well as general medical information about your child.
General History: High Risk Populations for Visual Problems
No
No Has your child been diagnosed with a syndrome (e.g. Down syndrome, CHARGE Yes syndrome, etc.?) Has your child been diagnosed as having cerebral palsy? Yes
Yes No Does your child have any difficulties with his or her hearing?
Yes No Does your child have any neurological disorders (e.g. seizures, hydrocephaly)?
No Has your child experienced any form of brain injury / head trauma? (in utero Yes stroke, brain hemorrhage, lack of oxygen, accidental or non-accidental trauma)
Yes No Has your child had meningitis or encephalitis?
Yes No Was your child exposed to alcohol or drugs before birth?
Yes No Was your child born prematurely?
No Yes Did your baby weigh fewer than three pounds at birth? No Yes Was your child exposed to any prenatal infections (e.g. toxoplasmosis, CMV)?
Yes No Is there a family history of eye crossing, color vision problems, and/or needing prescription glasses?
No Is there a family history of early onset vision loss (e.g., cataracts, albinism, etc.?) Yes
1
Mya Reid 8/15/18
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M.Reid (4)
2
The ABCs of Early Vision Problems
Background Information: We can learn a lot about the health and well-being of a young child’s vision by paying attention to the appearance of his or her eyes, visual behaviors, and complaints. Thank you for your assistance with this information to determine if there is a concern about your child’s vision.
Appearance of the Eyes / Eyelids: Please take a few moments to observe the child eyes and eyelids.Answer yes or no the statements below. If you are unsure, leave the question blank for consultation from Part C or school district Child Find professionals with appropriate expertise.
One eye looks different than the other eye. For example, one eye is significantly smaller in appearance or one eye is higher on the face than the other eye.
Yes No
One or both eyes turn inward or outward. This can happen all of the time or only some of the time.
Yes No
There is a difference in the black color, size or shape of the pupils in one or both eyes. The pupil is the dark black center of each eye.
Yes No
There is a difference in the size and shape of the iris in one or both eyes. The iris is the colored part of each eye.
Yes No
One or both eyes appear white or cloudy. Yes No
Eyes are in involuntary, rapid (dancing/ jiggling up and down or side to side) motion.
Yes No
Eye(s) are red and/or excessively mattered (beyond the usual sleep matter when the child first awakens or due to allergies).
Yes No
Eyelids are red, swollen, and/or are encrusted. Yes No
An eyelid(s) is drooping or appears lower than the other. Yes No
✔
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M.Reid (4)
3
Behavior: Please report your observations of how your child uses vision in daily tasks. Answer yes or nothe statements below. If you are unsure, leave the question blank for consultation from Part C or school district Child Find professionals with appropriate expertise.
Does your child …. Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Consistently NOT make eye contact with familiar people (after two months of age).
Cover or close an eye when looking at someone or something within close range (two feet or closer). Frown or squint an eye when looking at something far away (two feet or further).
Tilt / turn head to the side, lift /lower chin, and/or thrust head forward or backward when looking at something at near or far range. Circle which behavior occurs. Close eyes or turns face away when listening to others talk.
mile in response to another person’s smile.
Hold an object very close to his or her eyes when looking at it.
Stare at lights sources (overhead lights or windows) for a long period of time.
Prefer certain colors; chooses items with these colors over items with other colors. (e.g., seems to look more intently at objects that are red.)
Recognize familiar people only after they speak.
Notice people, pets, or objects only when they are moving
Seem to have inconsistent visual abilities (e.g. seems to change from morning to night or from day to day or between activities).
Miss objects he or she is simultaneously looking at and reaching for (e.g. require multiple attempts to get the item). Look away when reaching toward a nearby object.
Stumble frequently over objects that are in his or her path or bump into walls.
Have difficulties detecting a change in floor surface, such as from tile to carpet. Hesitate or miss detecting step or a curb.
Yes No
Have trouble seeing small objects, such as a small piece of cereal left on tray / table. Yes No
Lose interest quickly in games, projects or activities that require using his or her eyes for an extended period of time.
Yes No
Avoid looking at books, drawing, playing games or doing other projects that require focusing up close.
Yes No
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M.Reid (4)
Complaints: A young child will not usually “complain” about visual difficulties, but may show throughbehavior that something is not right with his or her vision. Answer yes or no the statements below. If you are unsure, leave the question blank for consultation from Part C or school district Child Find professionals with appropriate expertise.
Does your child …. Appear to be overly sensitive to bright indoor lights or the sunlight. Squint excessively, put a hand over his eyes, or put his head down to avoid the light.
Yes No
Seem to have burning or itchy eyes, rub his or her eyes, rapidly blink, and/or have teary eyes not due to allergies.
Yes No
Rub his or her eyes or blink rapidly after looking at something (when he or she is not tired).
Yes No
Appear to only see an object when it’s separated (isolated?) from other items (e.g. cannot find a specific toy when it’s among other objects).
Yes No
Do you have any concerns about your child’s vision that were not addressed in the previous questions? If yes, please describe.
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Has your child ever been seen by an eye doctor (optometrist or ophthalmologist?) Yes No
If yes, what were the results of the exam? _____________________________________________
____________________________________________________________________________________________________________
No
No
Were glasses or another treatment prescribed? Yes
If yes, does your child wear the glasses, as prescribed? Yes
If not, what is the reason the child is not wearing his or her glasses:
______________________________________________________________________________
Next Steps: Thank you for providing information about your child’s vision. This information will be reviewed with your Part C or Child Find contact person to determine appropriate next steps.
References:
Colorado Department of Education (2005). Visual Screening Guidelines: Children Birth through Five Years, Colorado Department of Education.
Teach CVI (2020). Screening List for Children with a Suspicions of a Cerebral Visual Impairment CVI) / Screen List CVI 1 retrieved from https://f9d3e3e2-4dd0-4434-a4bb-27a978ad3a27.filesusr.com/ugd/eca85c_7ca670026a8d4f388c5d63828ec0610d.pdf
Topor, I. (2004). Approximate functional visual acuity for different sizes of objects and distances. Chapel Hill,
NC: Early Intervention Training Center for Infants and Toddlers with Visual Impairments, FPG Child Development Institute, UNC-CH.
4
None
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M.Reid (4)
Vision Screening Parent Questionnaire for Children Ages Birth through Five Years
Child’s Name: Child’s DOB: ____________________
regi NaCa ver me: Date: __________________________
Community Center Board: District: ________________________
Contact Person: Email: __________________________
This tool has been developed to address cursory vision screening practices for children ages birth through five years of age. It should be completed by a caregiver who knows the child best. The information will determine if there are vision concerns that warrant further evaluation when in-person screening or assessment activities can resume.
It is important to have information about possible vision concerns that may occur with other family members, as well as general medical information about your child.
General History: High Risk Populations for Visual Problems
No
No Has your child been diagnosed with a syndrome (e.g. Down syndrome, CHARGE Yes syndrome, etc.?) Has your child been diagnosed as having cerebral palsy? Yes
Yes No Does your child have any difficulties with his or her hearing?
Yes No Does your child have any neurological disorders (e.g. seizures, hydrocephaly)?
No Has your child experienced any form of brain injury / head trauma? (in utero Yes stroke, brain hemorrhage, lack of oxygen, accidental or non-accidental trauma)
Yes No Has your child had meningitis or encephalitis?
Yes No Was your child exposed to alcohol or drugs before birth?
Yes No Was your child born prematurely?
No Yes Did your baby weigh fewer than three pounds at birth? No Yes Was your child exposed to any prenatal infections (e.g. toxoplasmosis, CMV)?
Yes No Is there a family history of eye crossing, color vision problems, and/or needing prescription glasses?
No Is there a family history of early onset vision loss (e.g., cataracts, albinism, etc.?) Yes
1
Kaylani Shaver 6/26/18
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K.Shaver (5)
2
The ABCs of Early Vision Problems
Background Information: We can learn a lot about the health and well-being of a young child’s vision by paying attention to the appearance of his or her eyes, visual behaviors, and complaints. Thank you for your assistance with this information to determine if there is a concern about your child’s vision.
Appearance of the Eyes / Eyelids: Please take a few moments to observe the child eyes and eyelids.Answer yes or no the statements below. If you are unsure, leave the question blank for consultation from Part C or school district Child Find professionals with appropriate expertise.
One eye looks different than the other eye. For example, one eye is significantly smaller in appearance or one eye is higher on the face than the other eye.
Yes No
One or both eyes turn inward or outward. This can happen all of the time or only some of the time.
Yes No
There is a difference in the black color, size or shape of the pupils in one or both eyes. The pupil is the dark black center of each eye.
Yes No
There is a difference in the size and shape of the iris in one or both eyes. The iris is the colored part of each eye.
Yes No
One or both eyes appear white or cloudy. Yes No
Eyes are in involuntary, rapid (dancing/ jiggling up and down or side to side)motion.
Yes No
Eye(s) are red and/or excessively mattered (beyond the usual sleep matter when the child first awakens or due to allergies).
Yes No
Eyelids are red, swollen, and/or are encrusted. Yes No
An eyelid(s) is drooping or appears lower than the other. Yes No
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K.Shaver (5)
3
Behavior: Please report your observations of how your child uses vision in daily tasks. Answer yes or nothe statements below. If you are unsure, leave the question blank for consultation from Part C or school district Child Find professionals with appropriate expertise.
Does your child …. Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Consistently NOT make eye contact with familiar people (after two months of age).
Cover or close an eye when looking at someone or something within close range (two feet or closer). Frown or squint an eye when looking at something far away (two feet or further).
Tilt / turn head to the side, lift /lower chin, and/or thrust head forward or backward when looking at something at near or far range. Circle which behavior occurs. Close eyes or turns face away when listening to others talk.
mile in response to another person’s smile.
Hold an object very close to his or her eyes when looking at it.
Stare at lights sources (overhead lights or windows) for a long period of time.
Prefer certain colors; chooses items with these colors over items with other colors. (e.g., seems to look more intently at objects that are red.)
Recognize familiar people only after they speak.
Notice people, pets, or objects only when they are moving
Seem to have inconsistent visual abilities (e.g. seems to change from morning to night or from day to day or between activities).
Miss objects he or she is simultaneously looking at and reaching for (e.g. require multiple attempts to get the item). Look away when reaching toward a nearby object.
Stumble frequently over objects that are in his or her path or bump into walls.
Have difficulties detecting a change in floor surface, such as from tile to carpet. Hesitate or miss detecting step or a curb.
Yes No
Have trouble seeing small objects, such as a small piece of cereal left on tray / table. Yes No
Lose interest quickly in games, projects or activities that require using his or her eyes for an extended period of time.
Yes No
Avoid looking at books, drawing, playing games or doing other projects that require focusing up close.
Yes No
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K.Shaver (5)
Complaints: A young child will not usually “complain” about visual difficulties, but may show throughbehavior that something is not right with his or her vision. Answer yes or no the statements below. If you are unsure, leave the question blank for consultation from Part C or school district Child Find professionals with appropriate expertise.
Does your child …. Appear to be overly sensitive to bright indoor lights or the sunlight. Squint excessively, put a hand over his eyes, or put his head down to avoid the light.
Yes No
Seem to have burning or itchy eyes, rub his or her eyes, rapidly blink, and/or have teary eyes not due to allergies.
Yes No
Rub his or her eyes or blink rapidly after looking at something (when he or she is not tired).
Yes No
Appear to only see an object when it’s separated (isolated?) from other items (e.g. cannot find a specific toy when it’s among other objects).
Yes No
Do you have any concerns about your child’s vision that were not addressed in the previous questions? If yes, please describe.
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Has your child ever been seen by an eye doctor (optometrist or ophthalmologist?) Yes No
If yes, what were the results of the exam? _____________________________________________
____________________________________________________________________________________________________________
No
No
Were glasses or another treatment prescribed? Yes
If yes, does your child wear the glasses, as prescribed? Yes
If not, what is the reason the child is not wearing his or her glasses:
______________________________________________________________________________
Next Steps: Thank you for providing information about your child’s vision. This information will be reviewed with your Part C or Child Find contact person to determine appropriate next steps.
References:
Colorado Department of Education (2005). Visual Screening Guidelines: Children Birth through Five Years, Colorado Department of Education.
Teach CVI (2020). Screening List for Children with a Suspicions of a Cerebral Visual Impairment CVI) / Screen List CVI 1 retrieved from https://f9d3e3e2-4dd0-4434-a4bb-27a978ad3a27.filesusr.com/ugd/eca85c_7ca670026a8d4f388c5d63828ec0610d.pdf
Topor, I. (2004). Approximate functional visual acuity for different sizes of objects and distances. Chapel Hill,
NC: Early Intervention Training Center for Infants and Toddlers with Visual Impairments, FPG Child Development Institute, UNC-CH.
4
Yes, my child only looks briefly. She doesn't focus on me.
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K.Shaver (5)
Vision Screening Parent Questionnaire for Children Ages Birth through Five Years
Child’s Name: Child’s DOB: ____________________
regi NaCa ver me: Date: __________________________
Community Center Board: District: ________________________
Contact Person: Email: __________________________
This tool has been developed to address cursory vision screening practices for children ages birth through five years of age. It should be completed by a caregiver who knows the child best. The information will determine if there are vision concerns that warrant further evaluation when in-person screening or assessment activities can resume.
It is important to have information about possible vision concerns that may occur with other family members, as well as general medical information about your child.
General History: High Risk Populations for Visual Problems
No
No Has your child been diagnosed with a syndrome (e.g. Down syndrome, CHARGE Yes syndrome, etc.?) Has your child been diagnosed as having cerebral palsy? Yes
Yes No Does your child have any difficulties with his or her hearing?
Yes No Does your child have any neurological disorders (e.g. seizures, hydrocephaly)?
No Has your child experienced any form of brain injury / head trauma? (in utero Yes stroke, brain hemorrhage, lack of oxygen, accidental or non-accidental trauma)
Yes No Has your child had meningitis or encephalitis?
Yes No Was your child exposed to alcohol or drugs before birth?
Yes No Was your child born prematurely?
No Yes Did your baby weigh fewer than three pounds at birth? No Yes Was your child exposed to any prenatal infections (e.g. toxoplasmosis, CMV)?
Yes No Is there a family history of eye crossing, color vision problems, and/or needing prescription glasses?
No Is there a family history of early onset vision loss (e.g., cataracts, albinism, etc.?) Yes
1
Zoe Willis 1/19/18
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Z.Willis (6)
2
The ABCs of Early Vision Problems
Background Information: We can learn a lot about the health and well-being of a young child’s vision by paying attention to the appearance of his or her eyes, visual behaviors, and complaints. Thank you for your assistance with this information to determine if there is a concern about your child’s vision.
Appearance of the Eyes / Eyelids: Please take a few moments to observe the child eyes and eyelids.Answer yes or no the statements below. If you are unsure, leave the question blank for consultation from Part C or school district Child Find professionals with appropriate expertise.
One eye looks different than the other eye. For example, one eye is significantly smaller in appearance or one eye is higher on the face than the other eye.
Yes No
One or both eyes turn inward or outward. This can happen all of the time or only some of the time.
Yes No
There is a difference in the black color, size or shape of the pupils in one or both eyes. The pupil is the dark black center of each eye.
Yes No
There is a difference in the size and shape of the iris in one or both eyes. The iris is the colored part of each eye.
Yes No
One or both eyes appear white or cloudy. Yes No
Eyes are in involuntary, rapid (dancing/ jiggling up and down or side to side) motion.
Yes No
Eye(s) are red and/or excessively mattered (beyond the usual sleep matter when the child first awakens or due to allergies).
Yes No
Eyelids are red, swollen, and/or are encrusted. Yes No
An eyelid(s) is drooping or appears lower than the other. Yes No
✔
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Z.Willis (6)
3
Behavior: Please report your observations of how your child uses vision in daily tasks. Answer yes or nothe statements below. If you are unsure, leave the question blank for consultation from Part C or school district Child Find professionals with appropriate expertise.
Does your child …. Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Consistently NOT make eye contact with familiar people (after two months of age).
Cover or close an eye when looking at someone or something within close range (two feet or closer). Frown or squint an eye when looking at something far away (two feet or further).
Tilt / turn head to the side, lift /lower chin, and/or thrust head forward or backward when looking at something at near or far range. Circle which behavior occurs. Close eyes or turns face away when listening to others talk.
mile in response to another person’s smile.
Hold an object very close to his or her eyes when looking at it.
Stare at lights sources (overhead lights or windows) for a long period of time.
Prefer certain colors; chooses items with these colors over items with other colors. (e.g., seems to look more intently at objects that are red.)
Recognize familiar people only after they speak.
Notice people, pets, or objects only when they are moving
Seem to have inconsistent visual abilities (e.g. seems to change from morning to night or from day to day or between activities).
Miss objects he or she is simultaneously looking at and reaching for (e.g. require multiple attempts to get the item). Look away when reaching toward a nearby object.
Stumble frequently over objects that are in his or her path or bump into walls.
Have difficulties detecting a change in floor surface, such as from tile to carpet. Hesitate or miss detecting step or a curb.
Yes No
Have trouble seeing small objects, such as a small piece of cereal left on tray / table. Yes No
Lose interest quickly in games, projects or activities that require using his or her eyes for an extended period of time.
Yes No
Avoid looking at books, drawing, playing games or doing other projects that require focusing up close.
Yes No
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Z.Willis (6)
Complaints: A young child will not usually “complain” about visual difficulties, but may show throughbehavior that something is not right with his or her vision. Answer yes or no the statements below. If you are unsure, leave the question blank for consultation from Part C or school district Child Find professionals with appropriate expertise.
Does your child …. Appear to be overly sensitive to bright indoor lights or the sunlight. Squint excessively, put a hand over his eyes, or put his head down to avoid the light.
Yes No
Seem to have burning or itchy eyes, rub his or her eyes, rapidly blink, and/or have teary eyes not due to allergies.
Yes No
Rub his or her eyes or blink rapidly after looking at something (when he or she is not tired).
Yes No
Appear to only see an object when it’s separated (isolated?) from other items (e.g. cannot find a specific toy when it’s among other objects).
Yes No
Do you have any concerns about your child’s vision that were not addressed in the previous questions? If yes, please describe.
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Has your child ever been seen by an eye doctor (optometrist or ophthalmologist?) Yes No
If yes, what were the results of the exam? _____________________________________________
____________________________________________________________________________________________________________
No
No
Were glasses or another treatment prescribed? Yes
If yes, does your child wear the glasses, as prescribed? Yes
If not, what is the reason the child is not wearing his or her glasses:
______________________________________________________________________________
Next Steps: Thank you for providing information about your child’s vision. This information will be reviewed with your Part C or Child Find contact person to determine appropriate next steps.
References:
Colorado Department of Education (2005). Visual Screening Guidelines: Children Birth through Five Years, Colorado Department of Education.
Teach CVI (2020). Screening List for Children with a Suspicions of a Cerebral Visual Impairment CVI) / Screen List CVI 1 retrieved from https://f9d3e3e2-4dd0-4434-a4bb-27a978ad3a27.filesusr.com/ugd/eca85c_7ca670026a8d4f388c5d63828ec0610d.pdf
Topor, I. (2004). Approximate functional visual acuity for different sizes of objects and distances. Chapel Hill,
NC: Early Intervention Training Center for Infants and Toddlers with Visual Impairments, FPG Child Development Institute, UNC-CH.
4
None
Poor vision
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Z.Willis (6)
